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4. Clinicians should closely monitor patients to determine whether any serious side effects emerge for a particular patient group or patient characteristic. Current research on adverse effects often fails to account for third-variable moderator effects, whereby a negative health outcome, which is thought to be benign or non-existent, suddenly manifests and/or becomes clinically significant for patients with particular characteristic.

5. Fluoxetine should be prescribed if clinically viable. There appears to be least uncertainty about fluoxetine. There is preponderance of evidence on this SSRI, compared with other antidepressants.

6. Given the flaws in existing literature antidepressants should only be prescribed for more severe cases of PND. Midwifes can play an important role in identifying such cases (see below).

Implications for midwifes

Midwifes play a key role in screening for antenatal and postnatal depression (Tully et al, 2002). The current review suggests that screening is essential, not just to identify cases of PND, but also to differentiate between mild and more severe cases, and also obtain essential background information on the patient.

Although the adverse effects of antidepressants, particularly SSRIs and TCAs, are generally benign, the paucity of randomised clinical trials and long-term assessments means that the safety of antidepressants cannot be taken for granted. Thus, the RCP (2004, 2006) recommends that antidepressants be used for severe or protracted (rather than milder) cases of PND. Midwifes have a responsibility for identifying such cases, primarily using the EPDS. However, it remains unclear the extent to which midwifes are trained for and involved in PND screening.

Consequently Tully et al (2002) conducted a study to assess the experience and role of midwifes in identifying and referring antenatal and postnatal depression cases, and current policies and practices in maternity units on this issue. Any deficiencies in training, practice, and policies would need to be addressed, in view of the importance of identifying mild and severe cases of PND.

Questionnaire data was collected from 182 maternity units in England and Wales. A letter was sent to the head or senior midwife in each unit, with a request that the questionnaire be completed by the midwife in the unit with the most experience of antenatal and postnatal depression. The questionnaire contained items concerning policies, guidelines, and practices regarding screening and management of pre- and postnatal depression.

Regarding policies/guidelines, only a minority (8%) of units had regulations on the management of PND. Furthermore, just over half (58%)undertook universal screening of PND, with 42% not doing so. Of the units that performed universal screening, the vast majority (93%) used the EPDS, while the rest employed other screening tools. Additionally, screening was undertaken primarily by a health visitor in the bulk of units (91%).

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